RC226 Using the Medical RC226 Using the Medical Image Resource Center Image Resource Center (MIRC) Software (Basic (MIRC) Software (Basic Imaging Informatics)Imaging Informatics)

Adam E. Flanders, MDThomas Jefferson University HospitalPhiladelphia, Pennsylvania

Using MIRC for Using MIRC for Departmental Teaching Departmental Teaching Files Files

Segment ObjectivesSegment Objectives

Features of a digital teaching file.Features of a digital teaching file. The MIRC solutionThe MIRC solution MIRC design features.MIRC design features. TJUH configuration(s) of MIRC TJUH configuration(s) of MIRC

software.software. Challenges of departmental DTF Challenges of departmental DTF

deployment.deployment.

What is a Teaching File?What is a Teaching File?

An organized repository of clinical An organized repository of clinical images and documentation.images and documentation.

Used primarily to supplement learning Used primarily to supplement learning process for trainees.process for trainees.

Source material for lectures, Source material for lectures, publications.publications.

Film library modelFilm library model Shelves of cases (film jackets)Shelves of cases (film jackets) Organized by anatomy, disease, ACR codes.Organized by anatomy, disease, ACR codes.

What are the Qualities of a What are the Qualities of a “Great” Radiology Teaching “Great” Radiology Teaching

FileFile High quality ImagesHigh quality Images Comprehensive supplemental Comprehensive supplemental

Information:Information: path reports, path images, discussion etc.path reports, path images, discussion etc.

OrganizationOrganization Indexed and searchableIndexed and searchable Fresh content.Fresh content. Easily accessed from anywhere.Easily accessed from anywhere. Easy to navigate.Easy to navigate. SecureSecure

Problems with Film-Problems with Film-Based TFBased TF Limited access.Limited access.

Typically, a lot of work to Typically, a lot of work to submit a case.submit a case. Difficult to solicit Difficult to solicit

“voluntary” contributions.“voluntary” contributions. Difficult to keep Difficult to keep

organized.organized. Missing or misfiled cases Missing or misfiled cases

or films.or films. Need a librarian/policemanNeed a librarian/policeman Securing files = limited Securing files = limited

access.access. Searching file is Searching file is

problematic.problematic. Inconvenient to use for Inconvenient to use for

decision support.decision support. Difficult to Difficult to

update/maintain – update/maintain – keeping material keeping material current.current.

Analog to Digital Analog to Digital TransformationTransformation

Inexpensive digital cameras / Inexpensive digital cameras / scanners.scanners.

Retirement of hard copy Retirement of hard copy (film)(film)

Proliferation of PACS.Proliferation of PACS. Proliferation of workstations.Proliferation of workstations.

Digitizing Analog ImagesDigitizing Analog Images

Digitizing Analog ImagesDigitizing Analog Images

Digital Camera on PACS or ViewboxLaborious but effective!

Personal Image Personal Image Storage Storage

SolutionsSolutions

Digitized Images: Big Step Digitized Images: Big Step Forward!Forward!

AdvantagesAdvantages Lightweight and reusableLightweight and reusable No deterioration, loss, resistant to theft.No deterioration, loss, resistant to theft. ModifiableModifiable Easy to adjust, crop, contrast, brightnessEasy to adjust, crop, contrast, brightness Easy to add annotation.Easy to add annotation.

ProblemsProblems Access remained limited.Access remained limited. Organization!Organization! Large collections, difficult to find images Large collections, difficult to find images

without meticulous labeling methodswithout meticulous labeling methods Sharing material?Sharing material?

Where to Put Your Images? - Personal Where to Put Your Images? - Personal DTFDTF

Copy images Copy images into folders into folders labeled labeled appropriatelappropriately.y.

Nested file Nested file structurestructure

Need to Need to open open content in content in another another application application for use.for use.

Not very Not very versatileversatile

Personal Teaching FilesPersonal Teaching Files Thousands of radiologists have amassed Thousands of radiologists have amassed

“personal” collections of images.“personal” collections of images. Solutions include cases on email, upload Solutions include cases on email, upload

of cases to free digital photo services (ie of cases to free digital photo services (ie Ophoto, Picassa, Shutterfly etc.)Ophoto, Picassa, Shutterfly etc.)

Generally used by a single user.Generally used by a single user. Accessible from a single computerAccessible from a single computer Image collections are limited in scope.Image collections are limited in scope. Difficult to enhance content.Difficult to enhance content. Not readily sharableNot readily sharable

Personal DTF Organization Personal DTF Organization with Picassawith Picassa

The Next PhaseThe Next Phase Web browser is the most appropriate vehicle Web browser is the most appropriate vehicle

for delivery of educational content.for delivery of educational content. Browsers are designed to display written Browsers are designed to display written

and visual content efficiently.and visual content efficiently. Including multimedia.Including multimedia. Early DTF contained “static” web pages.Early DTF contained “static” web pages.

Laborious to produce.Laborious to produce. Modern DTF coupled to a database Modern DTF coupled to a database

generates content dynamically (“on-the-fly”).generates content dynamically (“on-the-fly”). Easier to modifyEasier to modify More conducive to search mechanismsMore conducive to search mechanisms

Components of a Modern Components of a Modern DTFDTF

FileserverFileserver DatabaseDatabase WebserveWebserve

rr

Fileserver

Database

Webserver

Ethernet

What Do People Want?What Do People Want?

Radiologists want a simple method Radiologists want a simple method to create teaching materials from to create teaching materials from their existing PACS systems.their existing PACS systems.

Ease of useEase of use Time efficientTime efficient Simple to accessSimple to access Scalable in terms of size & Scalable in terms of size &

complexity.complexity.

What Is Available NOW?What Is Available NOW?

Commercial turnkey systems available Commercial turnkey systems available for a price which will provide:for a price which will provide: Method to save images & data from Method to save images & data from

PACS.PACS. Storage local or off-site for your casesStorage local or off-site for your cases Web server to display casesWeb server to display cases

Organizational repositories (e.g. ACR Organizational repositories (e.g. ACR Case-In-Point, Aunt Minnie etc.)Case-In-Point, Aunt Minnie etc.)

You can develop your own…You can develop your own… Or there is MIRC!!!!Or there is MIRC!!!!

What Does The MIRC What Does The MIRC Software Suite Do For Me?Software Suite Do For Me?Medical Imaging Resource Center

Da’ AnswerDa’ Answer

Set of software tools that allow you to Set of software tools that allow you to create, index, search and display create, index, search and display teaching materials.teaching materials.

Repository for educational content.Repository for educational content. Ability to selectively share this Ability to selectively share this

material in a consistent manner material in a consistent manner within your institution on your local within your institution on your local intranet or worldwide on the internet.intranet or worldwide on the internet.

MIRC ComponentsMIRC Components

Web serverWeb server File serverFile server Self updating indexSelf updating index Powerful administrative Powerful administrative

functionsfunctions

MIRC FeaturesMIRC Features Individualized file storageIndividualized file storage Multiple document “templates”Multiple document “templates” Multiple methods to author contentMultiple methods to author content Multiple methods to display contentMultiple methods to display content Web-based DICOM viewer.Web-based DICOM viewer. Web-based editor.Web-based editor. DICOM receiver (DICOM SCP)DICOM receiver (DICOM SCP) DICOM anonymizerDICOM anonymizer Administrative control of viewing, editing, Administrative control of viewing, editing,

deletion.deletion. Scalable and expandable from one author/PC to Scalable and expandable from one author/PC to

hundreds.hundreds. Easy to install & configure.Easy to install & configure.

MIRC ServicesMIRC Services

MIRC functions are known as MIRC functions are known as servicesservices File service File service Storage serviceStorage service Query service Query service Author serviceAuthor service Submit serviceSubmit service DICOM serviceDICOM service

Most services can be administered.Most services can be administered.

Scalability of MIRCScalability of MIRC MIRC has the unique ability to scale from MIRC has the unique ability to scale from

one computer / one user to many one computer / one user to many computers / many users.computers / many users.

Potential configurations include:Potential configurations include: One MIRC repository for one or more users.One MIRC repository for one or more users. Multiple MIRC repositories in one or many Multiple MIRC repositories in one or many

institutions.institutions. Software enables development of Software enables development of

cooperative libraries.cooperative libraries. Each library is individually administered yet Each library is individually administered yet

portions can be made accessible to all.portions can be made accessible to all.

MIRC MIRC CommunityCommunity

InternetInternet

ServerServer

Index

ServerServer

IndexMIRC site

ServerServer

Index

QueryService

MIRC siteServerServer

Index

RSNA site

User

MIRC site

MIRC Software Supports MIRC Software Supports Many Storage Formats.Many Storage Formats.

Images: DICOM, GIF, JPEG, Images: DICOM, GIF, JPEG, PNGPNG

Hyperlinks to other web Hyperlinks to other web content.content.

Virtually any content that is Virtually any content that is displayable in a web browser.displayable in a web browser.

Pointers to other files for Pointers to other files for downloading.downloading.

Display support for other types Display support for other types in the future…in the future…

Key MIRC Server Key MIRC Server ComponentsComponents

Storage Service (Warehouse for material)Storage Service (Warehouse for material) A cooperating information library.A cooperating information library. IndexIndex: the library’s card catalog.: the library’s card catalog. ServerServer: the library’s shelves.: the library’s shelves. Responds to MIRCquery using the Responds to MIRCquery using the

MIRCqueryresponse schema.MIRCqueryresponse schema. Query Service (“Google-like” search Query Service (“Google-like” search

portal)portal) An entry point into the MIRC community for a user An entry point into the MIRC community for a user

on the Internet.on the Internet. Creates queries using Creates queries using MIRCquery schemaMIRCquery schema..

MIRC TF Configuration MIRC TF Configuration ScenariosScenarios

Private ModePrivate Mode Departmental Departmental

ModeMode Division ModeDivision Mode Worldwide ModeWorldwide Mode VariationsVariations

MIRC TF ScenariosMIRC TF ScenariosPrivate (selfish) ModePrivate (selfish) Mode

My Stuff

Single-user Single-user contributorcontributor

Single-user Single-user accessaccess

No sharing No sharing of contentof content

MIRC TF ScenariosMIRC TF ScenariosDivisional / Semi-Private ModeDivisional / Semi-Private Mode

Each division or key Each division or key individual maintains a individual maintains a server.server.

Division is responsible Division is responsible for maintaining their for maintaining their content.content.

All or a portion of All or a portion of content can be made content can be made public.public.

Any individual can Any individual can access public records access public records on other MIRC on other MIRC servers within servers within institution.institution.

Much more difficult to Much more difficult to administer.administer.

MIRC TF ScenariosMIRC TF ScenariosDepartmental ModeDepartmental Mode Multiple users or Multiple users or

divisions contribute divisions contribute to a single to a single departmental MIRC departmental MIRC server.server.

All users have All users have controlled access.controlled access.

All can view public All can view public cases.cases.

Only owners can Only owners can modify data.modify data.

Private cases are Private cases are supported.supported.

One server to One server to manage for all manage for all content.content.

Easier to administer.Easier to administer.

BIG MIRC

NeuroNeuro NMNM ChestChest

CTCT Body Body MRMR

MammMammoo

CVIRCVIR MSKMSK PrivatePrivate

Neuro

MSK

Mammo

User

MIRC TF ScenariosMIRC TF ScenariosWorldwide ModeWorldwide Mode

Multiple MIRC Multiple MIRC sites sites (“MIRClets”) (“MIRClets”) expose content expose content to the Internet.to the Internet.

This public This public content is content is accessible to accessible to other computers other computers that can perform that can perform a query of MIRC a query of MIRC content.content.

Internet

The TJU The TJU ExperienceExperience

MIRC TF Installation at MIRC TF Installation at TJUTJU

Two MIRC servers currently installed.Two MIRC servers currently installed. One departmental (private) server One departmental (private) server

behind university firewall (2003 Server)behind university firewall (2003 Server) One Neuroradiology (public) server One Neuroradiology (public) server

residing on the public DMZ of the residing on the public DMZ of the firewall (2000 Server).firewall (2000 Server).

UsesUses Primarily Teaching FilesPrimarily Teaching Files Repository for clinical research data.Repository for clinical research data.

Public Neuroradiology Public Neuroradiology ServerServer

Resides on the public internet.Resides on the public internet. Contains interesting Neuroradiology/ENT Contains interesting Neuroradiology/ENT

cases.cases. Is listed with the RSNA portal.Is listed with the RSNA portal. Contains a subset of our proprietary DTF.Contains a subset of our proprietary DTF.

Does not contain the majority of our DTF.Does not contain the majority of our DTF. Uses:Uses:

PR device for the division.PR device for the division. Provides opportunity for former fellows to Provides opportunity for former fellows to

“give back” to the division.“give back” to the division. Consultation cases are reviewed in weekly Consultation cases are reviewed in weekly

case conference.case conference.

Features of the Public TF Features of the Public TF MIRCMIRC

Internet

Public NeuroradiologyMIRC Server

firewall

“Home Grown” Neuroradiology DTF

Linked to PACS

Public User

Selected Neuro/ENT Cases Are Pushed Out to Public

NeuroRadiology MIRC ServerUsing Custom Script

Cases on NeuroRadiology/ENT MIRC Server are Available for

Public Access

Registered Author

Registered Authors (former fellows & staff) Can Contribute to the Public

NeuroRadiology/ENT MIRC Server

How is the Public Site How is the Public Site Used?Used?

Public Teaching File Repository for Public Teaching File Repository for Neuroradiology/ENT Cases.Neuroradiology/ENT Cases.

Repository for Repository for consultconsult cases from cases from prior fellows and colleagues.prior fellows and colleagues.

Marketing tool for the TJUH Marketing tool for the TJUH NeuroRad fellowship.NeuroRad fellowship.

Central image server for multi-Central image server for multi-institutional SCI pharma imaging institutional SCI pharma imaging data.data.

Private Departmental MIRC Private Departmental MIRC ServerServer

Departmental MIRC ServerDepartmental MIRC Server

Serves multiple functions.Serves multiple functions. Heterogeneous case mix (> 12,000 cases)Heterogeneous case mix (> 12,000 cases) Largest proportion MSK (>8300 cases).Largest proportion MSK (>8300 cases). Over four thousand Neuro/ENT cases Over four thousand Neuro/ENT cases

from “home-grown” server are indexed on from “home-grown” server are indexed on server with links back to DTF (index server with links back to DTF (index card).card).

Provides support for four clinical research Provides support for four clinical research databases.databases.

““Feeds” to Departmental MIRC Feeds” to Departmental MIRC ServerServer

Teaching Cases

Exported from PACS

Teaching Cases

Exported from Other DTF using ZIP Service

NeuroDTF Index

NeuroDTF Index

Image Storage for Research

Departmental MIRC Departmental MIRC ServerServer

Departmental MIRC Departmental MIRC ServerServer

HAGL

Users of Departmental Users of Departmental ServerServer

Medical studentsMedical students ResidentsResidents FellowsFellows Rad FacultyRad Faculty Trainees & staff from clinical Trainees & staff from clinical

servicesservices ResearchersResearchers

Uses of Dept MIRC Uses of Dept MIRC Teaching FileTeaching File

Decision SupportDecision Support Source of images for Source of images for

presentations.presentations. Case ConferencesCase Conferences Pre-boards warmupPre-boards warmup

The Single The Single Biggest Obstacle Biggest Obstacle to Success in the to Success in the

DTF World….DTF World….Compliance with Compliance with

the authoring the authoring process.process.

Community vs Personal Community vs Personal LibrariesLibraries

MIRC supports creation of “private” MIRC supports creation of “private” libraries.libraries.

The best way to realize the full The best way to realize the full potential of a shared community potential of a shared community teaching collection is to build a teaching collection is to build a community of users/contributerscommunity of users/contributers..

The value of MIRC software, is that The value of MIRC software, is that you can support both!you can support both!

The Authoring The Authoring ProblemProblem

Lessons LearnedLessons Learned The MIRC software suite is scalable: from The MIRC software suite is scalable: from

a single user/contributor private DTF to a a single user/contributor private DTF to a large multi-user/multi-contributor public large multi-user/multi-contributor public DTF.DTF.

The software The software will not build the collection will not build the collection for you…for you… Only people will!Only people will!

The only way to build a great collection is The only way to build a great collection is to encourage multi-user contribution and to encourage multi-user contribution and to build a community that promotes to build a community that promotes knowledge sharingknowledge sharing..

Even with the best of intentions, it is not as Even with the best of intentions, it is not as easy as you might think!easy as you might think!

Lessons LearnedLessons Learned The biggest obstacles to creating a useful The biggest obstacles to creating a useful

teaching repository are not technical.teaching repository are not technical. The “ownership” issue…The “ownership” issue… Community property or personal Community property or personal

property?property? Building a great collection requires Building a great collection requires

cooperation from the community (the cooperation from the community (the entire department or division).entire department or division).

Collecting images and a diagnosis are a Collecting images and a diagnosis are a good start, but is not enough.good start, but is not enough. Need librarians that will create complete Need librarians that will create complete

documentation of cases.documentation of cases.

Lessons LearnedLessons Learned Authoring must occur at the Authoring must occur at the

point-of-care, that is during point-of-care, that is during clinical readout.clinical readout.Avoid retrospective submission.Avoid retrospective submission.

Authoring process must be Authoring process must be fast fast and ridiculously simple!and ridiculously simple!At minimum, key images, At minimum, key images,

diagnosis, and a clinical history.diagnosis, and a clinical history.The rest can be supplemented The rest can be supplemented

later.later.

Lessons LearnedLessons Learned Case material with limited content Case material with limited content

have limited value.have limited value. Most of our cases are Dx and images Most of our cases are Dx and images

alone.alone. Limited content still has value for:Limited content still has value for:

Decision supportDecision support Case conferencesCase conferences Creating presentationsCreating presentations Self-assessment board prep.Self-assessment board prep.

Limited content not effective for Limited content not effective for self-study.self-study.

Lessons LearnedLessons Learned Shame people into cooperating!Shame people into cooperating! Make the process fun!Make the process fun! Incorporate your DTF into a regular case Incorporate your DTF into a regular case

conference.conference. Even “suspicious” people will gradually see Even “suspicious” people will gradually see

the benefit.the benefit. Have a periodic Have a periodic Unknown of the Month, Unknown of the Month,

Day or Week.Day or Week. Encourage trainees to submit answers.Encourage trainees to submit answers. Tie a prize or reward into most correct cases Tie a prize or reward into most correct cases

or most submissions.or most submissions. Ask staff/fellows to select favorite cases Ask staff/fellows to select favorite cases

for residents to review from collection. for residents to review from collection.

Lessons LearnedLessons Learned

Through group cooperation, we have Through group cooperation, we have amassed over 11,000 Neuroradiology cases amassed over 11,000 Neuroradiology cases (non-MIRC).(non-MIRC).

You need at least one person to champion the You need at least one person to champion the process!process!

Encourage staff, residents and fellows to Encourage staff, residents and fellows to contribute.contribute.

Participation is Participation is rewardedrewarded through discussion through discussion at the weekly case conference.at the weekly case conference.

Participation is Participation is rewarded rewarded by access to a by access to a large, indexed repository of images for self large, indexed repository of images for self learning, conferences and lectures.learning, conferences and lectures.

ConfessionConfession

Everything is not perfect at home…..Everything is not perfect at home….. Even in a Even in a controlledcontrolled environment in environment in

my own division, compliance with my own division, compliance with authoring is far from 100%.authoring is far from 100%. Staff tend to pass the buck to busy Staff tend to pass the buck to busy

trainees who trainees who “forget”“forget” to author at the end to author at the end of the day.of the day.

Variable definition of a Variable definition of a valuable casevaluable case.. Lack of appreciation of “the classics”.Lack of appreciation of “the classics”. A generalized “fear” to save a case A generalized “fear” to save a case

without pathologic proof.without pathologic proof. ““What if I’m wrong????”What if I’m wrong????”

ConfessionConfession My influence on other divisions in my own My influence on other divisions in my own

department has been less than ideal.department has been less than ideal. 22ndnd largest DTF collection is MSK (>10K largest DTF collection is MSK (>10K

cases) all located on a poorly organized cases) all located on a poorly organized fileserver.fileserver.

Pilot project: Converted >8K to MIRC, now Pilot project: Converted >8K to MIRC, now web enabled and indexed.web enabled and indexed.

Division director “prefers” the old method.Division director “prefers” the old method. Departmental PACS to MIRC authoring tool:Departmental PACS to MIRC authoring tool:

Utilization has been poor.Utilization has been poor. The reason? You need more than one The reason? You need more than one

champion in a large, dispersed department.champion in a large, dispersed department.

Final ThoughtsFinal Thoughts People will tend to gravitate to what People will tend to gravitate to what

they already know or do:they already know or do: Email images to themselves.Email images to themselves. Save images to USB/CD.Save images to USB/CD.

Changing behavior is difficult, unless Changing behavior is difficult, unless you can convince users that the you can convince users that the secondary gain is better than the current secondary gain is better than the current solution.solution.

Contributing to the TF must Contributing to the TF must tied to the tied to the academic mission.academic mission.

Make it fun! Make it fun!

The FutureThe Future The one The one keykey technical element to a successful technical element to a successful

departmental teaching file is to simplify the departmental teaching file is to simplify the authoring process so that it is authoring process so that it is inexcusable inexcusable not to be performed during clinical read out.not to be performed during clinical read out.

IHE has come to the rescue with the IHE has come to the rescue with the Teaching File and Clinical Trial Export Teaching File and Clinical Trial Export profile.profile.

PACS vendors PACS vendors mustmust be pressured into be pressured into supporting this profile.supporting this profile.

Four vendors at RSNA this year are Four vendors at RSNA this year are demonstrating this piece.demonstrating this piece.

SummarySummary MIRC Teaching File Software Suite offers a MIRC Teaching File Software Suite offers a

viable, robust and scalable system for viable, robust and scalable system for creating comprehensive DTF collections.creating comprehensive DTF collections.

The sofware is well supported by the RSNA.The sofware is well supported by the RSNA. Free for use – installation CD’s available!Free for use – installation CD’s available! Project is being driven by the user Project is being driven by the user

community.community. Two user group meetings at RSNA!Two user group meetings at RSNA!

Software itself will not build a great Software itself will not build a great collection:collection: People/Cooperation/Community are key!People/Cooperation/Community are key!